CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.75 64.75 37.00
Subtotal (Total Children Is Unduplicated) 1 1.75 64.75 37.00
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 7 8.00 70.64 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 7.00 75.60 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 8.00 174.32 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 3 3.00 163.14 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.00 190.86 31.81
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.00 50.00 50.00
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.50 187.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.50 194.25 55.50
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 4 8.00 599.14 74.89
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.00 566.14 94.36
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.00 532.28 133.07
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.50 828.64 87.23
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 23.50 1924.81 81.91
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 24.00 2148.42 89.52
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.00 194.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.00 339.50 48.50
SPCH-92506-SPEECH EVAL BY LICENSED SLP 5 5.00 242.50 48.50
Subtotal (Total Children Is Unduplicated) 40 133.00 8642.36 64.98
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 9.00 450.00 50.00
HERN-T1027SC-EI HEARING SERVICES AFTER SHINE 1 3.00 150.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 21 98.00 7196.68 73.44
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 25 187.75 12744.47 67.88
SHIN-T1027SC-INITIAL SHINE SERVICES, INDIVIDUAL 1 1.00 50.00 50.00
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 131.75 8943.19 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.50 59.40 13.20
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 60.00 30.00 0.50
Subtotal (Total Children Is Unduplicated) 66 496.00 29678.06 59.83
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Total 630.75 38385.17 60.86
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Number of Children (Unduplicated) With at Least One Service 88
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
740 630.75 38385.17 0.00
Other 0 0.00 0.00 0.00
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Total 740 630.75 38385.17 0.00